What should be the emergency department nurse's next action when a 6-year-old child has a systolic ...

A
Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child older than 1 year is 70 mm Hg plus two times the child's age in years. A systolic blood pressure of 58 mm Hg calls for immediate action. The nurse should be direct in relaying the child's condition to the physician. Comforting the child and assessing the respiratory rate do not address the problem of shock, which requires immediate intervention. Assessing the child's responsiveness is included in a neurological assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this child most likely requires intravenous fluids, the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.